From the Guidelines
The treatment for anal fissures should begin with conservative measures, including increased fiber intake, adequate hydration, and warm sitz baths, as recommended by the most recent guidelines 1. The primary goal of these measures is to soften stools, reduce pain, and promote healing.
- Increased fiber intake of 25-30g daily can help soften stools and reduce the risk of constipation.
- Adequate hydration with 8 glasses of water daily can also help soften stools and promote healing.
- Warm sitz baths for 10-15 minutes, 2-3 times daily, can help relax the anal sphincter and reduce pain. If these measures do not provide relief within 2-3 weeks, topical medications may be prescribed, including calcium channel blockers like diltiazem (2% ointment applied 3 times daily), which have been shown to be effective in promoting healing and reducing pain 1.
- Topical calcium channel blockers have been found to be more effective than glyceryl trinitrate and have fewer side effects, with healing rates ranging from 65 to 95% 1. For chronic fissures resistant to medical therapy, surgical options like lateral internal sphincterotomy may be considered, but this should be done with caution due to the potential risk of incontinence and other complications 1.
- Lateral internal sphincterotomy has been found to be effective in promoting healing, but it can be associated with minor, but sometimes permanent, defects in continence 1. It is essential to note that the treatment of anal fissures should be individualized, and the choice of treatment should be based on the severity of symptoms, the chronicity of the fissure, and the patient's overall health status.
- A recent systematic review and meta-analysis found that calcium channel blockers were more effective than glyceryl trinitrate and had fewer side effects, making them a preferred treatment option for anal fissures 1.
From the Research
Treatment Options for Anal Fissures
- Medical treatment is non-specific, aimed at softening the stool and facilitating regular bowel movements, resulting in healing of almost 50% of acute anal fissures 2
- Specific medical treatment can be offered to reversibly decrease hypertonic sphincter spasm, including:
- Surgical treatment is based on two principles that may be combined: decreasing sphincter tone and excision of the anal fissure, including:
- Other techniques have been described to reduce the risk of incontinence, such as calibrated sphincterotomy and sphincteroplasty 2
Effectiveness of Treatment Options
- Botulinum toxin is the more effective nonsurgical treatment, with a healing rate of 96% compared to 60% for nitroglycerin ointment 3
- Fissurectomy combined with Botulinum Toxin A injection has a healing rate of 90% 4
- Lateral internal sphincterotomy provides rapid and permanent recovery in more than 95% of patients, but is associated with a risk of minor incontinence 5